Provider Demographics
NPI:1659986552
Name:TADESSE, TADESSE G
Entity Type:Individual
Prefix:
First Name:TADESSE
Middle Name:G
Last Name:TADESSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2648 GRANITE HILL CIR APT B
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23225-2068
Mailing Address - Country:US
Mailing Address - Phone:202-641-2813
Mailing Address - Fax:
Practice Address - Street 1:2648 GRANITE HILL CIR APT B
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23225-2068
Practice Address - Country:US
Practice Address - Phone:202-641-2813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-09
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAH135887344600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes344600000XTransportation ServicesTaxi